Program Integration & Beyond: Lessons Learned from Six California Counties

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1 Program Integration & Beyond: Lessons Learned from Six California Counties Tiana Wertheim EXECUTIVE SUMMARY This project is about the integration of self-sufficiency programs that has taken place in a number of California counties. San Francisco is in the process of integrating its Medi-Cal and CalFresh programs, and poised to benefit from the best practices and lessons learned elsewhere. San Mateo graciously hosted this project, and five other counties were also interviewed: Orange, Placer, Sacramento, Santa Cruz, and Tulare. The primary questions explored were: Which counties integrate which programs, and why? What is the biggest challenge of integration? Which counties pay differential/higher classification to integrated workers? Post integration: What comes next? Major Findings of the case study include the following: 1. Five out of the six counties integrated Medi- Cal and CalFresh for intake and continuing. Only three counties have additionally integrated CalWORKs or General Assistance, and even then, those counties have done so only for intake and not continuing. 2. Program alignment is the biggest challenge of program integration. 3. Counties compensate workers who work on 3 4 programs, but not those who work on only two. 4. Counties are going to different lengths to refer clients to services beyond self-sufficiency programs. Santa Cruz has a best practice worth further investigation. The key recommendations for the San Francisco HAS to: 1. Do everything it can to align regulations and advocate for policy alignment. 2. If the county decides to integrate CalWORKs or General Assistance, consider a hybrid model in which intake is integrated, but not continuing. 3. Invest in staff; the more skills they have, the more integrated your programs will become. 4. Have realistic expectations about how long integration takes. 5. Once program integration and health care reform have stabilized, build cross-program referrals and follow-up into business process. Tiana Wertheim, Senior Administrative Analyst, San Francisco Human Services Agency 127

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3 Program Integration & Beyond: Lessons Learned from Six California Counties Tiana Wertheim Introduction There is consensus among counties on why integrate self-sufficiency programs in California county social services agencies, but there is less of a consensus on how to do so. San Francisco is in the middle of integrating its CalFresh (cf) and Medi-Cal (mc) programs, later to potentially be joined by Cal- WORKS (cw) or General Assistance (ga/caap). This paper strives to share lessons learned in six counties to inform San Francisco s planning. It also explores what may come next after integration: the institutionalization of cross-program referrals and follow-up. San Mateo graciously hosted this project. Research for this paper included interviewing six TABLE 1 Which Counties Have Integrated Which Programs? INTAKE Placer None None CONTINUING Orange CF/MC CF/MC Tulare CF/MC CF/MC Sacramento CF/MC CF/MC San Mateo CF/MC/ CW/GA All workers know at least 2 programs. (CW and GA are caseloads) Santa Cruz CF/MC/CW CF/MC/CW but NOT Welfare-to-Work CF = CalFresh; MC = Medi-Cal; CW = CalWORKs; GA = General Assistance people in San Mateo, and interviewing staff from the five other counties suggested by the Intelegy Corporation: Sacramento, Santa Cruz, Orange, Placer, and Tulare. While there is agreement among the majority of counties that the benefits of integration outweigh the complications of transition, they agree that some programs are easier to integrate than others. Counties have made different choices about which programs to integrate. Right now, five out of the six have integrated mc/cf programs for both intake and continuing. Only two, San Mateo and Santa Cruz, have integrated additional programs. Both of these counties have integrated intake services for CalWORKs. Yet, Santa Cruz is the only one that has integrated CalWORKs continuing. Even in that case, Santa Cruz has limited the inclusion of CalWORKs cases to those cases without employment services. San Mateo is the one county that includes General Assistance in its integrated screening and assessments. Placer County does not integrate any of its selfsufficiency programs. Placer tried twice to integrate cf/mc, but in both cases, due to struggles with limited policy alignment, it decided to revert back to its silo approach. Program Alignment: The Biggest Challenge of Integration Integration would be much easier, and make more sense, if policy and regulations of programs are aligned in a number of ways, including reporting frequencies and timing, how average monthly income 129

4 130 BASSC EXECUTIVE DEVELOPMENT TRAINING PROGRAM is determined, similar regulations for liquid assets and property verification, etc. All counties agree on this and support any effort to improve alignment. Alignment means less paperwork, less time wasted for the worker and the client, and reduced risk of errors. In particular, alignment of requirements would allow the client to submit forms and documents for multiple programs at the same time. This would allow a worker to process them at once, resulting in fewer administrative errors; it would also mean the client has less to remember and less to do. That said, even aligning just the renewal dates of Medi-Cal and CalFresh is no easy task. If an applicant applies for both programs on the same day, and is approved for both, his or her dates will be aligned. But when a client applies for both programs at a different time, he or she will have different reporting timeframes for each program. A recent change in CalFresh regulations (acl13-05) allows counties to reduce the amount of time before recertifications are due. This flexibility gives counties a bit of leverage to align cases, although the implementation will be complicated, take time, and address only a fraction of the alignment issues. In the meantime, Santa Cruz County has devised other efforts to align dates. First, within their task management system, Santa Cruz aligns due dates among programs. For example, processing an mc application is given a 30-day due date in alignment with cf regulations, even though legally the county has 45 days to process it. Processing work in the same timeframe makes sense for dual applications in particular. Santa Cruz County implements another strategy during cf recertification interviews. During those interviews, the worker notifies the cf client of potential eligibility for Medi-Cal. If the client applies at that time, and is approved, he or she will be on the same renewal clock for both programs. This strategy hits two birds with one stone: alignment and in-reach. Whether to Integrate CalWORKs and GA The policies and regulations of CalWORKs (cw) and ga programs are even more divergent than those of Medi-Cal and CalFresh. This means it is harder to integrate these programs, and therefore fewer counties have braved this territory. Two counties, San Mateo and Santa Cruz, have integrated cw for intake. San Mateo County does so for ga as well. For more than eight years, San Mateo s screening and assessment workers have been taking applications for all four programs. Most counties do not integrate cw/ga because detailed, divergent, and ever-changing rules make it too cumbersome for the worker to keep everything straight, and the risk of making a mistake does not outweigh the benefit. The director of the Intake Processing Center in San Mateo explains, You have to know all of the permutations. The amount of information, the complexity of it and the importance of it; it is too big for individual staff to keep up with case maintenance rules for four programs. Only one county, Santa Cruz, has braved the waters and integrated continuing services for cw cases, but this does not include cw cases on employment services. The face-to-face requirement for cw clients who are on Welfare-to-Work is not consistent with the requirements of other programs. No counties have integrated the continuing services for ga. With significantly different rules, it does not appear that the benefits of integration outweigh the costs for these services. Paying Differentials/Higher-Classifications to Integrated Workers Counties DO NOT pay workers a differential if they work on only two programs. (Sacramento County is the exception.) DIFFERENTIAL HIGHER CLASSIFICATION Orange 0 0 Sacramento 5% May, if add CW San Mateo N/A N/A Santa Cruz 0 0 Tulare 0 0

5 PARTICIPANTS CASE STUDIES CLASS OF Counties DO pay workers a differential/higher class if they work on 3 4 programs. San Mateo DIFFERENTIAL 9.2% (future 5.7%) for workers doing 4 programs, none for those doing 2 programs HIGHER CLASSIFICATION N/A Santa Cruz N/A YES Of the five counties in this study with integrated programs, only Sacramento pays a differential or higher classification for workers who work on only two programs. The two other counties, San Mateo and Santa Cruz, provide compensation only to workers who do 3-4 programs. More than eight years ago, San Mateo agreed to pay a 9.2% differential to workers who do four programs. In a recent meet and confer, management decided to only pay 5.7% going forward. Recommendations 1. Do everything to align policies and regulations among benefit programs. 2. If it is decided to integrate CalWORKs or ga, consider a hybrid model in which intake is integrated, but not continuing. 3. Invest in staff. Counties agree that the more an agency invests in staff, the more integrated a program will become. 4. Have realistic expectations about how long integration is going to take. 5. Once program integration and health care reform have stabilized, build cross-program referrals and follow-up into business process. Santa Cruz County provides a best practice model, which is discussed below. Beyond Program Integration Program integration typically refers to self-sufficiency programs. A client can access services for cf/ mc/cw/ga, or some combination of those, at the same time, same place, and be served by the same person/call-center. But what happens with clients whose needs go beyond those programs? For that, you need the institutionalization of referrals and follow-up across programs. A client comes in to apply for cf and mentions that she is caring for her elderly mother who lives with her. Does the worker just continue the cf interview? In most counties today, the answer is yes. In Santa Cruz County, however, the cf worker is expected to ask, Are you getting In-Home Support Services? If the client is not, Here is how you can apply; the phone number; where to go; and a copy of the application. The worker is expected to then explain how participating in ihss may impact the other programs in which she is enrolled. The worker then puts the referral in case comments so that the next worker can follow up. The Santa Cruz County Human Services Depart ment s internal website is designed to support this integrated cross-referral system. The home page prominently offers a link to information about finding a job, and applying for Healthy Families, ihss, Veterans Services, cf, mc, etc. (See Figure 1.) If one selects Home Care, he/she goes to a page outlining information about In-Home Support Services which allow one then to link to more details. Any page can be printed, and the worker is expected to print out and hand to the client the appropriate pages to the client, including forms, verification documents, etc. The site equips the worker to make an informed referral. Cross-referral and follow-up is a fundamental form of in-reach. It is built into the bones of business processes throughout the Santa Cruz Human Services Agency. Santa Cruz attributes its success to: Providing an easy to use service directory on their agency intranet; Establishing a clear expectation of workers; Building the practice into business process; Providing re-training reinforcement; and Making referrals transparent in case comments. Whereas the majority of county social services agencies are not making cross-referrals a

6 132 BASSC EXECUTIVE DEVELOPMENT TRAINING PROGRAM FIGURE 1 Santa Cruz s Human Services Agency s internal website: fundamental business process, Clarissa Simon of San Mateo reflected that it is a lost opportunity. She reflected that clients are a captive audience, and it is the mission of agencies to provide services to clients in need. When a client comes in our door, shouldn t I identify her basic needs, and if the services she needs are beyond the ones I am administering, shouldn t I at least point the client in the right direction? And better yet, next time I talk to her, check up to see how she fared? There is a lot to say about how thoroughly a worker should go to identify a need, or how to figure out whether someone may be a good candidate to apply for something, but suffice it to say that if a worker is told that that a client has a tremendous toothache and can t afford to go to the dentist, a worker should be able figure out how to find local, appropriate dental help. The key, then, will be to create and implement systems to follow up on referrals, to make sure a client a gets what he or she needs. Using technology and innovative business processes, this must be possible and is worth pursuing. Conclusion Six counties have shared their experiences, and two of them, Santa Cruz and San Mateo, point toward the next step: the integration of referrals beyond CalFresh, Medi-Cal, General Assistance and Cal- WORKs. While the transition to an integrated system will inevitably be bumpy and long, it is inspiring to envision the chapter beyond, in which clients will receive the full range of services for which they are eligible. Acknowledgements All of my foundational knowledge and experience for this project came from San Mateo, my host county. Linda Holman could not have been a more gracious and organized liaison. I thank her for her incredibly thoughtful direction. I can t thank enough the 11 people I interviewed, for all of the information and insights they shared. San Mateo County: Clarissa Simon, Deputy Director; Linda Holman, Human Services Manager; Griselda Ruiz, Trainer; Judith Rohl, a recent graduate from induction training; Navjeet Singh, Director of the Intake Processing Center; and Laura Grogan, Lead Worker. Orange County: Debra Baetz, Deputy Director. Placer County: Cheryl Davis, Director. Sacramento County: Lester Heatley, Division Manager; and Danni Van Lone, Program Manager. Santa Cruz County: Emily Balli, Service Center Man a ger. Tulare County: Vienna Barnes, Unit Manager CalWORKs.